Term | Definition |
Limiting Collection of PI | a clear link must be established between the information that is collected and the reason for doing so |
Master patient index | a database of all clients registered |
Canada Health Infoway | a federally funded organization with a mandate to facilitate the national implementation of electronic health records |
Health Information Management | A field in its own right |
eHealth | a general term used to describe electronic health information |
Electrical Medical Record | A legal health record in digital format. Contains client's health information collected by one or a group of providers in one location. It is a subset of the electronic health record (EHR) |
Health Information Custodian | a person, persons, or organization who has the responsibility for safekeeping and controlling personal health information in connection with the powers and duties performed |
fob | a small security device that can be added to a computer for access purposes. It displays a randomly generated access code that changes every few seconds. |
outguiding system or chargeout system | as system for keeping track of paper health records taken from their normal location |
electronic medical records systems | a total medical office systems, including both hardware and software, with the capability of replacing all components of a paper chart (health record) electronically |
decentralized | allows parts of the record to reside outside HIS |
Electronic Health Record | an accumulation of essential information from an individual's electronic medical records that is accessed electronically at different points of service for purposes of client care |
health record | any document relating to a health-care client. The term record is used for a single document, such as a doctor's note on an assessment or a lab report; it also refers to a collective of documents, such as a client's chart. |
health information | any information pertaining to someone's physical or mental health, condition, or infirmity, whether given orally or recorded in any manner, that is created or received directly or indirectly by a health professional or health organization. |
operative report | any surgical procedure will generate a report |
disposition | as long as a client is alive and has the potential to seek treatment, a health record remains active |
lock boxes | client has specifically asked the doctor to keep confidential |
color coding | combination of alphabetical or numeric with colour |
consent form | consent must be obtained in order to collect the information |
centralized | designate one location in which to house all records |
provision | distribution of and access to information is strickly controlled |
ID systems | each client is assigned a unique identifier |
challenging compliance | each organization must have a process in a place to handle complaints with respect to the way personal information is collected, used, or disclosed, or the manner in which the organization complies with the legislative |
eChart | electronic chart |
miscellaneous | growth charts, antenatal records, diabetic flow sheets |
personal information | includes information that may be considered factual or subjective |
openness | information about policies relating to the management of person information must be readily available to the clients |
accuracy | information should be accurate and complete in terms of how it is recorded to facilitate its proper use |
lab sheets | keep together with most current on top |
physical assessment | may be formally prepared or noted on the progress notes |
consecutive | normally used for records that are pre-numbered |
encounter record | occurs each time a client has an encounter with a health-care provider |
alphabetical | oldest and most straightforward; direct access system |
maintenance | organizing records through some kind of filing system |
pChart | paper chart |
accountablity | PIO who is ultimately responsible for the compliance of the organization with the standards spelled out in the act |
cumulative patient profile | provides a cumulative view of history and current health status |
history sheet | questionnaire that the client is asked to fill out on first visit |
numeric | requires an index; indirect access system |
purge | review and reorganize to remove outdated information that is no longer actively needed to provide care to the client |
terminal digit | segments a number into component parts |
list of allergies | should be noted in red and listed in a prominent place |
creation | the initial retrieval of information |
safeguards | the organization must take appropriate and practical measures to protect the information from unauthorized access, use or tampering |
archive | to remove a file from active status and store it in a secondary location or an a secondary medium |
unlawful access | violates the law and moral and ethical principles |
individual access | with written request to the PIO, clients shall be given access to their personal information |
limited use, disclosure & retention | you cannot use or disclose any information for purposes other than those for which it was collected; information must be kept only as long as its serves its intended purpose; information must be appropriately stored and destroyed |
identifying purposes | you must inform the clients of the purpose for the collection of their information either before or at the time of the collection |